North American Neuromodulation Society

Our Therapies

As described, neuromodulation consists of a wide variety of therapies utilized across a wide variety of different medical specialties. Most frequently, neuromodulation is associated with stimulation. Analogous to the use of a pace-maker, stimulation refers to stimulating a nerve or set of nerves using controlled electrical impulses to try and improve their overall functionality and restore movement or alleviate pain.

Targets for stimulation usually include the brain and spinal cord, but can also include the peripheral and autonomic nerves as well. Examples include spinal cord stimulation, vagal nerve stimulation, deep brain stimulation, and peripheral nerve stimulation. Please see below for additional information on each of these therapies.

Spinal Cord Stimulation

Spinal cord stimulation (SCS) delivers low level electrical stimulation to the spinal cord for the management of neuropathic pain and is an adjustable, non-destructive, neuromodulatory procedure. Pain is masked by changing the sensation from painful to a gentler, more soothing tingling sensation which masks the pain. The most common indications include post-laminectomy syndrome, complex regional pain syndrome (CRPS), chronic cervical and lumbar radiculopathy. Physicians have also used SCS for ischemic limb pain, angina. the treatment of intractable pain due to other causes including visceral/abdominal pain, cervical neuritis, spinal cord injury, post-herpetic neuralgia, and neurogenic pain secondary to thoracic outlet syndrome. Most studies indicate that, in carefully selected patients, SCS can produce at least 50% pain relief in at least 50%.

For additional Information, please see the following articles:

Spinal Cord Stimulation for Patients

Spinal Cord Stimulation for Practitioners

Changing how your brain senses pain

Deep Brain Stimulation

Deep brain stimulation (DBS) delivers electrical current to the deep structures of the brain. It has come to replace the once more common ablative procedures such as pallidotomy and thalamotomy to be an adjustable, neuromodulative procedure. It is used to treat a number of movement disorders including Parkinson’s disease, tremor, and dystonia. Targets include the subthalamic nucleus, globus pallidus, and thalamus. Many research studies have looked at DBS for the treatment of depression, obsessive compulsive disorder, anorexia, obesity, multiple sclerosis, and pain syndromes. Most recently, DBS has been at the forefront for the treatment of epilepsy.

Cortical stimulation has been used to treat pain patients for various syndromes from post stroke pain to neuropathic pain. It has become most widely used in the treatment of epilepsy. Investigative reports are looking at cortical stimulation for the treatment of movement disorders, depression, and stroke.

Peripheral Nerve Stimulation

Peripheral nerve stimulation (PNS) is a commonly used approach to treat pain. It involves a procedure that places a small electrical device (a wire-like electrode) that targets a named nerve or branch of a named nerve. (These are the nerves that are located beyond the brain or spinal cord). The electrode delivers electrical pulses to provide therapy either to create tingling (paresthesia) or non tingling (non-apresthesia) or a muscle response. 

With the evolution of imaging modalities like Ultrasound the scope of PNS has increased markedly for upper and lower extremities, cranial, occipital, lumbar, sacral, genitofemoral, ilioinguinal, axial and segmental nerves. The ability to place leads percutaneously near the neural fascicles without open dissection has significantly reduced morbidity of scarring and the mechanical challenges of previous surgical systems. (1-3). The procedure is primarily done in office setting under local anesthesia. 

Peripheral Nerve Stimulation continues to evolve with accrual of more robustly designed studies. Several trials have been published in the last decade to further advance our understanding of this novel therapy with potential new targets (4). 

Applications of PNS:

  • Analgesia
  • Bowel Incontinence (sacral nerve stimulation)
  • Bladder Incontinence (sacral nerve stimulation, Posterior Tibial Nerve Stimulation)

Some of the accepted and relatively well studied targets for PNS can be succinctly discussed in the following table (5,6,7):

Regions  Peripheral Nerves
CRANIAL  1. Occipital nerve
2. C2 Post-ganglionic nerve
OROFACIAL PAIN
CLUSTER HEADACHE
1. Sphenopalatine Ganglion
2. Supraorbital nerve
3. Infra orbital nerve
UPPER EXTREMITY 1. Median nerve
2. Ulnar nerve
3. Radial nerve
4. Brachial Plexus
5. Suprascapular nerve
6. Axially nerve
THORACIC & LUMBAR  1. Intercostal nerves
2. Cluneal nerves
3. Dorsal Cutaneous nerves of cervical, thoracic and lumbar spine
PELVIC 1. Ilioinguinal nerve
2. Iliohypogastric nerve
3. Genitofemoral nerve
4. Pudendal nerve
LOWER EXTREMITY 1. Lateral Femoral Cutaneous nerve
2. Peroneal nerve
3. Saphenous nerve
4. Post Tibial nerve
5. Sciatic nerve

 

Spinal Nerve Root Stimulation

Category Appropriate Level Advantages
Intraspinal C2-Coccygeal Can target multiple roots per electrode
Transforaminal Caudal thoracic-sacral Less likely to undergo migration than intraspinal placement
Extraforaminal Sacral Less invasive technique for targeting bladder roots
Trans-spinal C2-S1 Unaffected by epidural scarring, stenosis or fusion at adjacent levels

 

There are also published reports with successful use of PNS in a HYBRID neurostimulation paradigm for primarily axial low back pain in conjunction with Spinal Dorsal Column Stimulation (8,9).

The risks and benefits of the procedure should be individualized as per the comorbidities of patients and shared decision making should be encouraged in high risk patients (anticoagulation, high risk for infection, immunocompromised, cancer, etc).

The field of peripheral nerve stimulation is undergoing metamorphosis at a very rapid pace. Advancements into new indications, new stimulation targets and new device designs will expand the window of opportunity to attract more neuromodulators interested in the field of Peripheral Nerve Stimulation. The turning point, however, will not occur until sufficient scientific evidence is gathered to unequivocally prove its safety, clinical efficacy and cost effectiveness (10).

For more information on Peripheral Nerve Stimulation, click here.

Neuroprosthetics

Neuroprosthetics have been used for deafness with cochlear implants, as well as for blindness via retinal stimulation. Investigations have looked into artificial limbs and as an adjunct for rehab, as well as the involvement of what has been known as the brain-machine interface.

For additional reading, please click here.

Drug Delivery

Drug Delivery Devices are surgically implanted pumps that deliver medication directly to a desired target, most often the spinal cord or brain. This method of medication delivery directly into the central nervous system, enables a ,much lower dosage to be administered and decreases, if not eliminates many side effects seen with oral or other systemic administration. Implanted pumps are used in the treatment of pain syndromes such as chronic low back pain following surgery (failed back syndrome) or cancer pain, as well as for the treatment of spasticity seen with multiple sclerosis, stroke and spinal cord injury

Reference for Practitioners

Reference for Patients

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